Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments

Objectives The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). Methods A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. Results In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. Conclusions This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.

Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments

Objectives The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). Methods A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set, and; 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. Results At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors, and; 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. Conclusions This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.

Water in Action : Encounters among 2- to 3-Year-Old Children, Adults, and Water in Day Care

In line with cultural psychology and developmental theory, a single case approach is applied to construct knowledge on how children s interaction emerge interlinked to historical, social, cultural, and material context. The study focuses on the negotiation of constraints and meaning construction among 2-to 3-year-old children, a preschool teacher, and the researcher in settings with water. Water as an element offers a special case of cultural canalization: adults selectively monitor and guide children s access to it. The work follows the socio-cultural tradition in psychology, particularly the co-constructivist theory of human development and the Network of Meanings perspective developed at the University of São Paulo. Valsiner s concepts of Zone of Free Movement and Zone of Promoted Action are applied together with studies where interactions are seen as spaces of construction where negotiation of constraints for actions, emotions, and conceptions occur. The corpus was derived at a Finnish municipal day care centre. During a seven months period, children s actions were video recorded in small groups twice a month. The teacher and the researcher were present. Four sessions with two children were chosen for qualitative microanalysis; the analysis also addressed the transformations during the months covered by the study. Moreover, the data derivation was analyzed reflectively. The narrowed down arenas for actions were continuously negotiated among the participants both nonverbally and verbally. The adults expectations and intentions were materialized in the arrangements of the setting canalizing the possibilities for actions. Children s co-regulated actions emerged in relation to the adults presence, re-structuring attempts, and the constraints of the setting. Children co-constructed novel movements and meanings in relation to the initiatives and objects offered. Gestures, postures, and verbalizations emerged from the initially random movements and became constructed to have specific meanings and functions; meaning construction became abbreviated. The participants attempted to make sense of the ambiguous (explicit and implicit) intentions and fuzzy boundaries of promoted and possible actions: individualized yet overlapping features were continuously negotiated by all the participants. Throughout the months, children s actions increasingly corresponded adults (re-defined) conceptions of water researchers as an emerging group culture. Water became an instrument and a context for co-regulations. The study contributes to discussions on children as participants in cultural canalization and emphasizes the need for analysis in early childhood education practices on the implicit and explicit constraint structures for actions.

Initiating advance care planning on end-of-life issues in dementia: Ambiguity among UK and Dutch physicians

Background
In dementia, advance care planning (ACP) of end-of-life issues may start as early as possible in view of the patient’s decreasing ability to participate in decision making. We aimed to assess whether practicing physicians in the Netherlands and the United Kingdom who provide most of the end-of-life care, differ in finding that ACP in dementia should start at diagnosis.

Methods
In a cross-sectional study, we surveyed 188 Dutch elderly care physicians who are on the staff of nursing homes and 133 general practitioners from Northern Ireland. We compared difference by country in the outcome (perception of ACP timing), rated on a 1–5 agreement scale. Regression analyses examined whether a country difference can be explained by contrasts in demographics, presence, exposure and role perceptions.

Results
There was wide variability in agreement with the initiation of ACP at dementia diagnosis, in particular in the UK but also in the Netherlands (60.8% agreed, 25.3% disagreed and 14.0% neither agreed, nor disagreed). Large differences in physician characteristics (Dutch physicians being more present, exposed and adopting a stronger role perception) hardly explained the modest country difference. The perception that the physician should take the initiative was independently associated with agreeing with ACP at diagnosis.

Conclusions
There is considerable ambiguity about initiating ACP in dementia at diagnosis among physicians practicing in two different European health care systems and caring for different patient populations. ACP strategies should accommodate not only variations in readiness to engage in ACP early among patient and families, but also among physicians.

Interdependency and care over the lifecourse

Interdependency and Care over the Lifecourse draws upon theories of time and space to consider how informal care is woven into the fabric of everyday lives and is shaped by social and economic inequalities and opportunities. The book comprises three parts. The first explores contrasting social and economic contexts of informal care in different parts of the world. The second looks at different themes and dynamics of caring, using fictional vignettes of illness and health, child care, elderly care and communities of care. The book examines the significance to practices of care throughout the lifecourse of: understandings and expectations of care emotional exchanges involved in care memories and anticipations of giving and receiving care the social nature of the spaces and places in which care is carried out the practical time-space scheduling necessary to caring activities. Finally the authors critically examine how the frameworks of caringscapes and carescapes might be used in research, policy and practice. A working example is provided. This book will be of interest to students and researchers of care work, health and social care, geography, sociology of the family and social policy as well as those in business and policy communities trying to gain an understanding of how work and informal care interweave

Opportunistic assessment of hearing in elderly inpatients

Objective: To determine the prevalence of occult hearing loss in elderly inpatients, to evaluate feasibility of opportunistic hearing screening and to determine subsequent provision of hearing aids. Materials and methods: Subjects (>65 years) were recruited from five elderly care wards. Hearing loss was detected by a ward-based hearing screen comprising patient-reported assessment of hearing disability and a whisper test. Subjects failing the whisper test or reporting hearing difficulties were offered formal audiological assessment. Results: Screening was performed on 51 patients aged between 70 and 95 years. Of the patients, 21 (41%) reported hearing loss and 16 (31%) failed the whisper test. A total of 37 patients (73%) were referred for audiological assessment with 17 (33%) found to have aidable hearing loss and 11 were fitted with hearing aids (22%). Discussion: This study highlights the high prevalence of occult hearing loss in elderly inpatients. Easy two-step screening can accurately identify patients with undiagnosed deafness resulting in significant proportions receiving hearing aids.

Värdigt liv och välbefinnande, enligt vem? : en kvalitativ studie om brukare och biståndshandläggares beskrivningar av ett värdigt liv och välbefinnande : Dignity and well-being, according to whom? : a qualitative study of elderly and assistance officer´s descriptions of a dignified life and wellbeing

We are two students named Susanne Grönlund and Anna Zaar and have jointly worked together this c-essay called "dignity and well-being according to whom? The paper is written at Högskolan dalarna in Falun.The purpose of this study was to investigate how the elderly and assistance officer describes dignity and well-being and how it is consistent with the government's bill on the national values that the National Board has developed.Our empirical study consists of four qualitative interviews, two older people dependent on community care and two assistance officers. The study's theoretical basis is Antonovsky's salutogenic approach and SOC. The survey focuses on different themes such as dignity, integrity, participation, treatment, wellbeing, security and meaningfulness which are also central themes in the Government Bill on the national values for elderly.The results show that the respondents believe that a life of dignity is difficult to define and also a subjective experience. The results also show a consistency between what the elderly, assistance officer and the national values that define dignity and well-being. Social Services Act, national values should serve as a starting point for municipalities to improve elderly care, thereby creating a sense of coherence for the individual. Keywords: Elder care, dignity, integrity, participation, attitude, well-being, security and meaningfulness.

Äldre och ensamhet : En kartläggning av sociala insatser för äldre personer i Dalarnas kommuner

Det finns begränsat med forskning kring hur biståndshandläggare inom äldreomsorgen arbetar med ensamhet hos äldre personer. Med anledning av detta är studiens huvudsakliga syfte att undersöka hur biståndshandläggare i Dalarnas kommuner arbetar med att utreda sociala behov till följd av ensamhet hos äldre personer samt att ta reda på vilka kommunala sociala insatser som erbjuds för dessa individer och på vilka grunder. Studien är genomförd utifrån en kvantitativ ansats, där vi har använt oss av en enkät, som innehåller frågor som avser att besvara syftet. Tolkningsramen för analysen av det empiriska materialet utgörs av Lipskys teori om gräsrotsbyråkrati. Studiens resultat visar att det finns behov av att både utöka och utveckla kommunernas utbud av sociala insatser för äldre personer samt att utveckla rutiner för hur man ska arbeta med ensamhet hos äldre personer. Studien påvisar ett behov av mer forskning, både internationell och nationell, kring hur biståndshandläggare arbetar med att identifiera ensamhet hos äldre personer.

Unlicensed personnel administering medications to older persons living at home : a challenge for social and care services

BACKGROUND: Administration of medication to care recipients is delegated to home-care assistants working in the municipal social care, alongside responsibility for providing personal assistance for older people. Home-care assistants have practical administration skills, but lack formal medical knowledge. AIM: The aim of this study was to explore how home-care assistants perceive administration of medication to older people living at home, as delegated to them in the context of social care. METHODS: Four focus groups consisting of 19 home-care assistants were conducted. Data were analysed using qualitative content analysis. RESULTS: According to home-care assistants, health and social care depends on delegation arrangements to function effectively, but in the first place it relieves a burden for district nurses. Even when the delegation had expired, administration of medication continued, placing the statutes of regulation in a subordinate position. There was low awareness among home-care assistants about the content of the statutes of delegation. Accepting delegation to administer medications has become an implicit prerequisite for social care work in the municipality. CONCLUSIONS: Accepting the delegation to administer medication was inevitable and routine. In practice, the regulating statute is made subordinate and consequently patient safety can be threatened. The organisation of health and social care relies on the delegation arrangement to meet the needs of a growing number of older home-care recipients. IMPLICATIONS FOR PRACTICE: This is a crucial task which management within both the healthcare professions and municipal social care needs to address, to bridge the gap between statutes and practice, to create arenas for mutual collaboration in the care recipients' best interest and to ensure patient safety.

Envelhecimento populacional: um diagnóstico dos idosos institucionalizados, em Natal/RN

The aging process lived by the Brazilian population concurred to the transformation in the family models, causing difficulties related to the elderly care on the Family environment, a fact that is one of the main reasons for their institutionalization. Facing this scenario, the need of investigating how the elderly lives on the long-term facilities (ILPI) has aroused. In this study, it has been conducted an analysis of the populational aging process, contrasting the Rio Grande do Norte to Brazil and the Northeast Region, between 1980 to 2010. Faced with the realization of this process, and the rising number of long-term facilities for the elderly (ILPI), it was needed to make a rescue of the abiding laws regarding elderly institutionalization, on the scope of Natal, which surged after the 1988 Federal Constitution, checking what were the impacts on the assistance of the institutionalized elderly. Lastly, it were investigated the possible determinants associated with the institutionalization, in Natal-RN, considering the aspects of the family structure, family relationship, economic, health and well being of the elderly. The results showed that Rio Grande do Norte, particularly Natal, follows the national scene, since between 1980 and 2000 its population passed the intermediate level in the process of population aging for, in 2010, to be considered elderly. Throughout this process, it was observed that Natal has been adapting to the federal legislation, through the creation of the municipal policy, City Council and other relevant standards for the elderly, promoting significant changes in ILPI.However, philanthropic institutions needs better resources for their maintenance. In research with the elderly, it was found that although the majority of the elderly have declared themselves satisfied with life, they had indicators of impairment of functional capacity and cognitive, isolated social behavior and depression, affecting the life quality of these elderly. These results reflect the need for greater investment of public power in the drafting, implementation and monitoring of public policies aimed at promoting changes that raise the level of life quality of this segment of the population

Care arrangements for people with dementia in developing countries

Background: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. Methods: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. Results: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. Conclusions: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world. Copyright © 2004 John Wiley & Sons, Ltd.

Depression severity levels and cognitive functions in institutionalized elderly patients

Depression is a highly prevalent illness among institutionalized aged and assumes peculiar characteristics such as the risk for progressing to dementia. The aims of this study was to assess the cognitive functions of institutionalized elderly with clinical diagnosis of depression and compare the severity of depressive symptoms with cognitive performance. From 120 residents at a nursing home in Rio Claro, Brazil, we study 23 individuals (mean age: 74.3 years; mean schooling: 4.0 years) with diagnosis of depression. At first, a clinical diagnosis of depression and measurement of its symptoms using the Geriatric Depression Scale were performed. The patient then underwent a neuropsychological assessment based on the following tests: Mini-Mental Examination, Verbal Fluency, Visual Perception, Immediate Memory, Recent Memory, Recognition, Clock Drawing Test. The patients were divided into two groups: those with less severe depression symptoms (Group 1: N=9) and more severe symptoms (Group 2: N=14). The significant difference between symptom severity of the two groups was p=0.0001. Patients with more severe symptoms revealed a slightly inferior cognitive performance in most of the tests when compared to those with less severe symptoms (p>0.05). In relation to Verbal Fluency, patients with more severe depression symptoms presented a significantly inferior cognitive performance when compared to those with less severe symptoms (p=0.0082). Verbal Fluency revealed to be a more sensitive test for measuring early cognitive alterations in institutionalized aged with depression, and appears to be a useful resource in monitoring the cognitive functions of patients faced with the risk of dementia. © Copyright Moreira Jr. Editora.

Effects of motor intervention in elderly patients with dementia: An analysis of randomized controlled trials

The objective of this study was to analyze randomized controlled trials published in the last decades involving motor intervention as a treatment for dementia, based on Physiotherapy Evidence Database (PEDro) criteria. A database search was performed using the following keywords: randomized controlled trial, dementia, physiotherapy, physical therapy, occupational therapy, physical education, motor approach, exercise, and physical activity. Ten trials were found: 4 related to physiotherapy, 3 to occupational therapy, 1 to physical education, and 2 to interdisciplinary motor intervention. The efficacy of motor intervention was confirmed in the following variables: psychosocial function, physical health and function, affective status, and caregiver's distress (P < .05). Results related to mobility were not significant (P > .05). Behavior, cognitive performance, activities of daily living, and risk of falls were not similar among the articles. From a total score of 10 points, with excellence characterized as the highest punctuation, the articles were classified between 3 and 7 by PEDro. Motor intervention was shown to be an alternative for minimizing physical and mental decline. PEDro has been confirmed as a very reliable tool to analyze studies and as an evaluation criteria, both qualitative and quantitative, allowing the establishment of motor intervention strategies for the treatment of patients with dementia. © 2007 Lippincott Williams & Wilkins, Inc.

Risk factors for vascular dementia in elderly psychiatric outpatients with preserved cognitive functions

The aim of the study was to assess risk factors for vascular dementia (VaD) in elderly psychiatric outpatients without dementia, and to determine to what extent clinical interventions targeted such risk factors. Out of 250 clinical charts, 78 were selected of patients over 60 years old, who showed no signs of dementia. Information was obtained regarding demographics, clinical conditions (diagnosis according to ICD-10), complementary investigation, cognitive functions (via CAMCOG), neuroimaging, and the presence of risk factors for VaD. Depression was the most prevalent psychiatric disorder (74%). A great majority of the patients (86%) had at least one risk factor for VaD. One-third of the sample showed three or more risk factors for VaD. The clinical conditions related to risk factors for VaD were hypertension (48.7%), heart disease (30.8%), hypercholesterolemia (25.6%), diabetes mellitus (23.1%), stroke (12.8%), tryglyceride (12.8%), and obesity (5.1%). In terms of lifestyle, smoking (19.2%), alcohol abuse (16.7%), and sedentarism (14.1%) were other risk factors found. Definite risk factors for VaD were found in 83.3% of the patients. Previous interventions targeting risk factors were found in only 20% of the cases. The high rates of risk factors for VaD identified in this sample suggest that psychiatrists should be more attentive to these factors for the prevention of VaD. © 2007 Elsevier B.V. All rights reserved.

Análise da prescrição de medicamentos de pacientes hipertensos atendidos pelo SUS da rede municipal de saúde de Rincão - SP

The purpose of this study was to identify the drugs most often prescribed for hypertension at the Municipal Health Care Center of the town of Rincäo, State of São Paulo, Brazil, and the principal interactions arising from their association with other drugs, both anti-hypertensives and those in other classes. The study included 725 hypertensive patients registered at this health care center who were regularly seen by a physician every three months. Data were collected on age, sex, occurrence of diabetes, smoking, sedentary lifestyle and overweight, to obtain a profile of the hypertensive population of the area. Control records of all patients were available at the pharmacy in the health care center, where patients obtained their drugs once a month. Of the 725 patients, 38% were male and 62% female. Most (57%) were between 50 and 70 years of age, 21% used tobacco and 43% led a sedentary lifestyle. Single-drug therapy accounted for 33% of the prescriptions, multidrug therapy for 66%. In addition to anti-hypertensives, 50% of the patients took drugs of other therapeutic classes. Of those receiving multidrug therapy, 34% used three or more anti-hypertensives and 66% used only two of these drugs. Drug interactions were detected in as many as 47% of the prescriptions. Captopril was the drug that showed most interactions with others (54%), followed by hydrochlorothiazide (27%), furosemide (14%), propanolol (4%), and nifedipine (1%). The analysis revealed that drug consumption by the patients investigated is high, with a concomitantly high number of episodes of drug interaction.